Compartment Syndrome Complication of Coronary Intervention Using Ulnar Artery Access

Abstract

Background

Compartment syndrome (CS) is a rare complication from ulnar artery access for coronary intervention.

Case Summary

An 84-year-old patient presented with acute coronary syndrome. Coronary intervention was performed using ulnar artery access after radial access was found to be unsuitable. Post-procedure, upper extremity hematoma progressed to CS. Surgical fasciotomy and ulnar artery repair was successful, but neurologic impairment remained.

Discussion

This patient represents a unique case of coronary intervention using ulnar artery access with resultant complications of hematoma and progression to CS. In this case, the multitude of vascular risk factors probably contributed to this complication. Early CS recognition by symptoms and examination was assisted by vascular ultrasound. Prompt surgical intervention with evacuation of the hematoma and arterial repair prevented tissue necrosis or possible amputation; however, lingering nerve damage remained.

Take-Home Message

Early recognition and appropriate management of ulnar artery–related CS is critical to minimize long-term complications.

Graphical Abstract

History of Presentation

An 84-year-old woman was admitted to the emergency department with shortness of breath. Initial evaluation revealed angina symptoms, electrocardiogram changes, and positive troponins. Cardiac consultation noted multiple coronary risk factors, including smoking history, high body mass index, hypertension, and hyperlipidemia and confirmed the diagnosis of acute coronary syndrome. She also had a history of chronic obstructive pulmonary disease and lung cancer. Initial differential diagnoses included pulmonary embolus, congestive heart failure exacerbation, and chronic obstructive pulmonary disease exacerbation. These were ruled out upon further diagnostic evaluation. The listed medications for the patient were aspirin 325 mg, diltiazem XR 120 mg, nebivolol 5 mg, and rosuvastatin 10 mg, all taken once daily.

Take-Home Messages

• •This case highlights the potential risks of hematomas in transradial and transulnar approaches, as well as the symptoms and methods of early diagnosis of potentially serious hematoma.
• •Tissue ischemia and neurologic impairment represent critical indicators of impending CS and the need for emergent surgical management to minimize long-term complications.

On the day after admission the patient consented and underwent cardiac catheterization with provisional coronary intervention. The standard right transradial approach was initially attempted; however, the wire could not be advanced. With ultrasound guidance, the operator decided to proceed with right transulnar access. In lieu of an Allen test, the operator determined arterial suitability with dual diagnostic ultrasound and angiography of the ulnar artery. Cardiac catheterization was completed using a 0.014 Choice PT wire and 5-F sheath and catheters (Figure 1A). Coronary intervention was performed with an upsize to 6-F catheters, and coronary stent placement to the proximal left anterior descending artery and diagonal branch was uncomplicated (Figure 1B). Closure of the ulnar artery was accomplished with no apparent complications.

Figure 1.

Coronary Angiography Preprocedure and Postprocedure

(A) Cardiac catheterization pre-percutaneous coronary intervention. (B) Coronary stents to the left anterior descending artery and first diagonal branch post-percutaneous coronary intervention.

Approximately 32 minutes after completion of the procedure, the patient developed excruciating, “burning like fire” right upper extremity pain, only partially relieved by morphine and subsequently fentanyl administration. An initial arterial ultrasound demonstrated no signs of occlusion of the radial artery; however, as the symptoms progressed over the next few hours a second ultrasound was ordered 5 hours after the initial procedure. The second ultrasound demonstrated unusual biphasic waveform with spectral broadening in the right brachial ulnar and radial arteries with patent palmar arch (Figure 2). No arterial occlusion or pseudoaneurysm was identified. Symptoms progressed, and the patient reported an inability to move her fingers and ongoing severe hand pain. At this point, the attending physician diagnosed severe compartment syndrome (CS) in the right forearm.

Figure 2.

Right Ulnar Artery Spectral Doppler Ultrasound Demonstrating Biphasic Waveform With Spectral Broadening in the Right Brachial Ulnar and Radial Arteries With Patent Palmar Arch

Management

Emergency hand surgery consultation was obtained, and the patient underwent surgical exploration of the right forearm with fasciotomy, evacuation of hematoma, repair of ulnar artery laceration, and application of wound vacuum-assisted closure (Figure 3). The surgeon confirmed the extensive hematoma was directly compressing the median nerve and identified an ulnar artery laceration as the bleeding source. Postoperatively, the color of the patient's arm and capillary flow to the hand improved significantly, and slow improvement was documented in the sensory and motor function of the fingers. After 3 additional forearm operations, the fasciotomy was closed 8 days after the initial procedure. The remainder of the hospitalization was uncomplicated, and the patient was discharged on the 9th hospital day.

Figure 3.

Right Forearm Immediately Post-Fasciotomy

Outcome and Follow-Up

The post-hospitalization care of this patient was critical to recover upper extremity sensory and motor function. The patient participated in more than 8 weeks of intensive physical and occupational therapy to regain motor function of her right hand, including feeding herself and brushing her teeth. At 10 months post-fasciotomy, the patient showed enough improvement to be discharged from long-term physical therapy (Figure 4). However, at 1-year post-fasciotomy, hand examination confirmed residual loss of upper extremity function due to median nerve damage.

Figure 4.

Right Forearm 1-Year Post Fasciotomy

Discussion

In this specific case, CS resulted directly from dissection and bleeding from the ulnar artery. Although similar radial artery cases have been reported, a novel analysis of this ulnar artery case highlights important clinical management features, including patient risk factors, procedural methodology, and emergency management.

In review of the decision to use ulnar access in this case, it is first important to acknowledge that upper extremity arterial access (either transradial or transulnar) for cardiac catheterization and coronary interventions has a lower risk of complications relative to transfemoral access. In this case, the radial approach was not feasible, and ulnar access was employed with the knowledge that there is a notable risk of possible complications.1, 2, 3 In routine catheterization, upper extremity hematoma and vascular occlusion occur in approximately 10% of cases and can vary in severity.⁴ However, progression of hematomas to acute CS has been reported in 0.1% to 0.3% of upper extremity vascular access cases.⁵ However, this patient had multiple high-risk clinical factors, including advanced age, female sex, obesity, hyperlipidemia, hypertension, heavy nicotine exposure, and use of antiplatelet and anticoagulant medications. In this case, the patient had specifically requested avoidance of a femoral artery approach, and the operator cautiously proceeded with ulnar access.

Catheterization procedure methodology that likely contributed to risk of CS included the decision to use the relatively smaller diameter ulnar artery in this elderly woman, even after the inability to access the radial artery. Although arterial access was guided by ultrasound, the use of 6-F catheters likely placed excessive lateral forces on the ulnar artery. It is also important to note that this patient developed hematoma and CS after a coronary intervention with the use of standard antiplatelet and anticoagulant medications (oral aspirin, clopidogrel, and heparin). The immediate discontinuation of antiplatelet medications and possible reversal of anticoagulants should be considered as options in all patients after coronary intervention with enlarging hematomas to prevent possible progression to limb-threatening CS.^6,7

This case clearly illustrates that early diagnosis and rapid treatment of any upper extremity hematoma within the first 4 hours is crucial for acute CS management. Whereas small hematomas are common, they can progress in severity to acute CS. The absence of pain, often due to subjectivity of pain thresholds and analgesic medications, can delay diagnosis. In addition, compartment rigidity can appear late in CS progression, also increasing diagnostic delay. In this case, the patient's severe pain and the physical examination findings of an enlarging forearm hematoma and pallor of the right hand and digits coupled with paresthesia confirmed the diagnosis of CS.

Bedside use of ultrasound-guided arterial Doppler identified an abnormal pulse waveform, providing supportive diagnostic information. Additional tools including tissue pressure monitors and standard angiography, although beneficial in some cases where the diagnosis is unclear, were not needed in this case. In selected cases of upper extremity hematoma, immediate return to the catheterization laboratory for angiography may confirm the bleeding source, and with experienced operators, vascular repair procedures may be effective to close the bleeding site and eliminate hematoma progression. Importantly, the loss of neurologic motor and sensory function directly led to the decision not to proceed with vascular repair, but instead to expedite emergency surgery consultation.

The most effective treatment in most upper extremity CS cases remains vascular surgery. As this case illustrates, with the occurrence of upper extremity hematoma and with the specific signs of rapid progression of tissue ischemia and loss of motor and sensory function, emergent vascular surgery was considered mandatory. The hand surgeon was able to respond in a timely manner, confirm the diagnosis of CS, perform a fasciotomy to relieve pressure, evacuate the hematoma, and identify and repair the bleeding source. Likely owing to the multiple high-risk clinical features and prior vascular disease, although rapid vascular surgery reversed the upper extremity ischemia with no loss of necrotic tissue, it did not prevent the morbidity of long-term residual median nerve damage. In most cases of CS, effective surgical treatment usually includes fasciotomy, hematoma evacuation, and repair of the bleeding source to successfully prevent progression of tissue necrosis, minimize neurologic injury, and salvage the limb from potential amputation.

Conclusions

As illustrated by this case, upper extremity CS is a serious potential complication of ulnar artery access for cardiac catheterization and coronary interventional procedures. All patients with upper extremity CS should be observed for hematoma, which should be aggressively managed to prevent progression. Early clinical recognition of classic symptoms, physical examination findings, and use of bedside diagnostic tools should confirm the diagnosis of CS. In cases of severe CS with worsening vascular and/or neurologic findings, it is imperative to activate emergent treatment. Prompt surgical consultation, evaluation, and emergency surgical fasciotomy are essential to minimize tissue ischemia and neurologic impairment. Future research is needed to develop effective and more accurate diagnostic tools and techniques that can identify early changes in upper extremity vascular perfusion, compartment pressure, and neurologic dysfunction before the critical point of impending tissue necrosis and permanent nerve injury.

Visual Summary.

Timeline of Intervention and Compartment Syndrome Recovery

Timeline	Events
Day 1	84-y-old woman was admitted to emergency department with shortness of breath, and clinical diagnosis of acute coronary syndrome was confirmed.
Day 2	Patient underwent right transulnar cardiac intervention. Shortly thereafter she developed symptoms of burning pain in her forearm. Initial ultrasound displayed nothing unusual; however, increasing pain warranted a second ultrasound 5 h later that demonstrated unusual biphasic waveform. The patient was then diagnosed with compartment syndrome and underwent an emergency fasciotomy, evacuation of the hematoma, and repair of the ulnar artery.
Day 8	After 3 additional procedures, the fasciotomy was closed.
Day 9	Patient was discharged from the hospital after 9 d and additional hand surgeries. Patient started physical therapy to regain neurologic function.
Day 365+	Patient’s arm function has recovered almost entirely with some residual neurologic damage.

Funding Support and Author Disclosures

This research was entirely self-funded. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Video 1 Summary of Case